Government funded suicide prevention in Australia – an environmental scan

Background Suicide is a worldwide public health problem. In response to this problem, Australia was one of the first countries to develop national suicide prevention policy. Guided by the National Suicide Prevention Office (NSPO), which was established in 2021, suicide prevention in Australia is in a period of reform. The NSPO is driving a nationally consistent and integrated approach to suicide prevention including leading the development of a new National Suicide Prevention Strategy. This article summarises findings from an environmental scan of government-led suicide prevention in Australia, conducted as an input for the development of the new Strategy. Methods The scan was conducted from August 2022 to January 2023. We searched relevant government websites and Google to identify policy documents and programs and services. We undertook a desktop review of documents and programs/services using coding templates developed to address the objectives of the scan. Qualitative information was extracted in a systematic manner using these templates. Results Australia’s suicide prevention efforts are significant as demonstrated by activities ranging from policy documents intended to guide and plan activity, the National Mental Health and Suicide Prevention Agreement committing the Federal Government and jurisdictions to work together, and the availability of national, state, local area based, and digital services and programs. Suicide prevention approaches in Australia are mostly selective or indicated. There is less emphasis on universal approaches, wellbeing promotion, strengthening protective factors and mitigating the impact of known drivers of distress. In addition, there is limited evidence to demonstrate a whole-of-government or whole-of-system approach is operating in Australia. Findings should be interpreted in the context that suicide prevention in Australia is currently in a period of transition. Conclusions Current government emphasis on and investment in suicide prevention activity, together with strong commitment to lived experience and cross sectorial collaboration, are substantial and appropriate. There are also many opportunities to further progress cross-portfolio and cross-jurisdiction suicide prevention and response efforts. This requires urgently adopting a shared understanding of suicide, which includes the diverse drivers of suicidal distress, and improving protective factors and social wellbeing.


Background
Suicide remains a pressing but preventable worldwide public health problem.Globally, around 703,000, people die by suicide each year [1].Effective strategies for preventing suicide include training general practitioners to recognise and treat depression, routine active follow-up of patients after discharge or a suicide-related crisis, means restriction, and educating young people about depression and suicidal behaviour [2,3].Combination approaches in health care systems show promise in reducing suicide in several countries, but evidence is yet to be amassed [2,3].The World Health Organization endorses four evidence-based suicide prevention interventions including means restriction; interacting with media for responsible reporting of suicide; fostering socio-emotional life skills in adolescents; and early identification, assessment, management and follow up of anyone affected by suicidal behaviours [4].
In response to the problem of suicide, three decades ago, Australia was one of the first countries to have commenced developing and supporting national suicide prevention policy.However, the Australian suicide prevention rate is not decreasing, with 3,249 deaths by suicide recorded in 2022, representing an age-standardised rate of 12.3 per 100,000 people [5].Furthermore, in Australia, suicide and self-inflicted injuries is the second leading cause of premature death from injury or disease and is the leading cause of premature death in men aged 15-49 years [6].
More recently, in 2019, the Federal Government announced the appointment of the first National Suicide Prevention Adviser to work with the National Suicide Prevention Taskforce to advise on reforming the suicide prevention system.The National Suicide Prevention Adviser's Final Advice (Final Advice) drew heavily on the views of people with lived experience of suicide, in addition to government, service provider organisations and leaders in Indigenous suicide prevention [7][8][9][10].The Final Advice is founded on 'whole of system, whole of life' principles, aiming to provide early intervention anywhere it could be needed in the service delivery system.This tenet is reliant on a whole-of-government approach to suicide prevention, which includes all government levels (Federal, state and territory, and local government) and all portfolios (not just health or mental health) working together on integrated policies and programs to prevent suicide and self-harm [7].
In 2021, the Federal Government announced the establishment of the National Suicide Prevention Office (NSPO) tasked with working across governments, portfolios, and sectors to drive the development of a nationally consistent and integrated approach to suicide prevention.This includes leading the development of a new National Suicide Prevention Strategy (Strategy), which will be followed by the development of a National Outcomes Framework and a National Suicide Prevention Workforce Strategy in 2024 [11].
Based on the blueprint for a public health, whole-ofgovernment approach to suicide prevention developed by Pirkis and colleagues [12,13], the Final Advice [7][8][9][10] and a range of other inputs, the NSPO has been iteratively developing a framework for the new Strategy structured around focus areas and enablers (Table 1) [14].The focus areas are the critical domains where action is required by governments and service providers to significantly reduce suicide and suicidality.The enablers are foundational areas of system reform required to drive the effective implementation of the Strategy as well as strengthen suicide prevention efforts more broadly.The enablers reflect some of the World Health Organization's endorsed necessary pillars for implementing suicide prevention in countries such as multisectoral collaboration; capacity building; and surveillance, monitoring and evaluation [4].
The NSPO commissioned the University of Melbourne's Centre for Mental Health (now named the Centre for Mental Health and Community Wellbeing) to conduct an environmental scan of the government-led suicide prevention system in Australia as an input for the development of the Strategy.The scan aimed to address the following research questions: 1. What are governments in Australia (Federal and state/territory) doing to prevent suicide? 2. To what extent is government-led suicide prevention activity in Australia aligned with the focus areas in the NSPO framework for the new Strategy?3. To what extent does government-led suicide prevention activity in Australia leverage the system enablers described in the NSPO framework for the new Strategy?
Table 1 NSPO framework for the development of the new National Suicide Prevention Strategy as at 2022 [14] Since writing this article, the framework for the Strategy has been refined through consultation with stakeholders and will be modified by the time of publication.Therefore, although the Strategy's refinements are consistent with the broad policy positions reflected and the findings in this article, readers should access the latest version of the Strategy

Concept Description
Focus areas This study reports the findings of this environmental scan, which may be used to inform the development of national approaches to suicide prevention in other highincome countries or to compare approaches between countries.

Data sources and scope
The scan was conducted from August 2022 to January 2023 and focused on two key methods: (1) a desktop review of government policy and agreement documents and (2) a scan of government-led/or directly funded programs and services.The former included Federal and state/territory documents and the latter focused on national programs and services.Supplementary key informant interviews were also conducted and will be reported separately.The scope of the environmental scan focused on government led activity because its findings will inform the development of the new National Suicide Prevention Strategy, which is a government-led document.

Government policy and agreement documents
We identified the current or most recent publicly available Australian suicide prevention 'policy documents' (e.g., government agreements, strategies and plans) by referring to documents mentioned in the National Suicide Prevention Adviser's Final Advice [7][8][9][10] and by using the search terms 'suicide prevention policy' , 'suicide prevention strategy' , 'suicide prevention plan' , and 'suicide prevention agreement' .These search terms were entered into the relevant websites including Federal, state and territory government; established suicide prevention organisations and agencies; Primary Health Networks (PHNs, which are funded by the Federal government and commission health services to meet needs of their local communities); and Google.The search was not restricted to health portfolios but included suicide prevention activities undertaken within any government portfolio or agency.

Programs and services scan
Because a single data source for programs and services was not found, we identified selected key programs and services in the national service system from similar websites used to identify policy documents, and contacted staff from relevant agencies to ensure that key initiatives about which information was not in the public domain were included in the scan.Only programs or services labelled, funded, or designed explicitly with the objective of suicide prevention were included.

Data extraction and analysis
We undertook a desktop review of documents collected.We developed coding templates based on the aims and objectives of the scan and on our discussions with the NSPO to summarise and organise salient themes as they emerged from the given data source.Separate coding templates were developed for the different focus areas and enablers, but we attempted to align the coding frameworks across different data sources.For example, data extracted from policy documents included: Title of policy document, Period, Who is involved, Roles and responsibilities, Key objectives, Approach/guiding principles/conceptual framework, Priority populations, Interventions/programs, Funding/budget, Monitoring/ evaluation/outcome measurement, and Evaluation of plan's progress in relation to suicide prevention activity.Data were also extracted from these documents on lived experience and workforce.
Qualitative information was extracted in a systematic manner using these templates.This analysis enabled us to describe areas of commonality and difference across policy documents.Having described each policy or program, we considered the extent to which their totality demonstrates progress within a particular focus area or enabler of the NSPO framework for the new Strategy.Progress was assessed as considerable, partial or mixed, absent, or not possible to assess.

Findings
Table 2 outlines the number and type of documents reviewed and data extracted.Appendix 1 provides a detailed list of the documents.
Findings are presented for each research question.Space does not permit a complete listing of activities, programs and services, so key examples are presented.

Research question 1. What are governments in Australia doing to prevent suicide?
Led by Federal and state and territory governments, Australia's suicide prevention and response efforts are extensive across five activity categories: (1) Strategies, plans, and frameworks, (2) the National Agreement, (3) Joint regional plans, (4) Key programs and services, and (5) Monitoring and evaluation.

Suicide prevention and response in policy documents (strategies, plans and frameworks)
Many Federal and state and territory strategies, plans and frameworks are in place, focussing explicitly on suicide prevention or considering it together with mental health.Most strategies include a consideration of priority populations and standalone national priority population suicide prevention strategies exist for First Nations peoples [15] and LGBTIQ + people, although government contributed to rather than developed the latter strategy [16,17].Federal mental health and wellbeing strategies for current and ex-Australian Defence Force (ADF) members [18,19] and children [20] include suicide prevention.
The Zero Suicide Framework, which aims to improve support for people in crisis presenting to emergency departments, was mentioned as a cross-portfolio initiative in several policy documents.For example, to improve data and evidence, the national Veteran Strategy mentions a formal monitoring and evaluation plan that will align with the Government's Towards Zero Suicides agenda [19].Queensland and New South Wales have published care pathways based on the Zero Suicide Framework [21,22].The Zero Suicide Framework is being implemented in Queensland to drive cultural and clinical change in suicide care across all hospital and health services [23], and in New South Wales to trial evidence-based peer support and peer-led initiatives as alternatives for people with suicidal ideation presenting to emergency departments [24].The South Australian plan also includes the Zero Suicide Framework [25].

National Mental Health and Suicide Prevention Agreement (National Agreement)
The National Agreement [26] is a key mechanism for formalising a joint Federal-state/territory approach including Federally funded PHNs and Medicare Benefits Schedule (MBS) services and state/territory government funded Local Hospital Networks (LHNs); as well as an explicit commitment to a whole-of-government approach to supporting and funding suicide prevention activity in portfolios other than health, e.g., education, justice, disability, housing etc.
Under the National Agreement [26], the Federal Government and state and territory governments are working together to support key initiatives including a Distress Brief Intervention (DBI) Trial, postvention services, and the national rollout of aftercare services for people following a suicide attempt (universal aftercare 1 ).Table 3 briefly describes these initiatives.

Joint regional plans for integrated mental health and suicide prevention
Under Australia's Fifth National Mental Health and Suicide Prevention Plan (Fifth Plan) [28], Federal, state and territory governments require PHNs and LHNs to jointly develop plans for integrated mental health and suicide prevention services in their local regions (geographic locations).These joint plans aim to address local servicebased problems faced by people with lived experience of mental illness or suicide and their carers and families, such as fragmentation, gaps, duplication and inefficiencies in service provision, and a lack of person-centred care [29].Joint regional plans have been developed for all of Australia's 31 PHN locations (one plan was published after our scan was completed, so is not included in this analysis).Plans cover periods of 2-5 years; some are foundational, and others outline activities and outcomes regarding strategic priorities.The Federal Government funds PHNs and joint local area-based regional planning and state and territory governments fund LHNs.Therefore, consistent with this framework, aftercare services -even if they target all people who have made a suicide attempt -are an indicated intervention [13].

Key programs and services
Australia's suicide prevention service system, comprising government agencies, service providers and the nongovernment sector, is complex [30].This section describes key initiatives other than those available through the MBS, from hospitals or under the National Agreement including: (1) the National Suicide Prevention Leadership and Support Program (NSPLSP), (2) PHN-commissioned services, (3) national digital mental health and suicide prevention services and programs, and (4) online navigation systems.

National Suicide Prevention Leadership and Support Program (NSPLSP)
The NSPLSP was introduced in 2017 as part of the Federal Government's response [31] to the National Review of Mental Health Programs and Services [32]  Most NSPLSP projects provide selective interventions targeting specific at-risk populations (e.g., youth, men experiencing psychosocial distress, people bereaved by suicide, people in rural/remote locations, veterans, LGB-TIQ +, and First Nations peoples); or people/organisations supporting them (e.g., PHNs).The NSPLSP also funds the CBATSISP.
The NSPLSP is currently being evaluated by Australian Healthcare Associates.Projects funded under the NSPLSP are evidence-informed [33] meaning they are based on a combination of research evidence, lived experience views, professional expertise, and information from the practice context [34].An earlier evaluation of the NSPLSP found that although there were reporting inconsistencies, most projects were achieving their targets and had the potential to strengthen or expand their activities through additional funding [35].It also found that a definition of suicide prevention leadership in the context of the NSPLSP was lacking, engagement (and associated outcomes) between PHNs and NSPLSP projects was mixed, project leaders were unaware of each PHNs have received funding to appoint a Suicide Prevention Regional Response Leader to work with communities in their catchment to determine local needs and target programs and services commissioned [17].
Many PHNs participated in multi-component program suicide prevention trials between 2017 and 2022; the evaluation findings from which have influenced policy directions [36,37].For example, the National Suicide Prevention Trial showed that four of 12 Trial Sites (11 PHNs) commissioned aftercare services for people who had attempted suicide or were experiencing a suicidal crisis, and all Trial sites commissioned a range of community-based activities including some led by non-government organisations [36].Community-based activities mostly involved either awareness raising and engagement activities or capacity building, such as providing training to community members, frontline workers and members of the health and allied health workforce on suicide prevention or offering mental health first aid training.
National digital mental health and suicide prevention services and programs Digital services are delivered remotely via telephone, videoconference, online chat, online course (self-or therapist-guided), secure mobile messaging (SMS) or mobile applications (apps).Digital mental health services have been funded by the Federal Government since 2006.Twenty digital mental health and suicide prevention services were reviewed as part of this scan irrespective of funding source either because they are suicide prevention or postvention specific, offer mental health support including the ability to manage suicidal distress, or target at-risk populations.Appendix 3 provides an overview of the characteristics of these 20 services.
Most of the 20 digital services reviewed provide selective (e.g., young people, First Nations peoples, people who identify as LGBTIQ+, veterans) or indicated interventions for anyone experiencing distress (including families and those bereaved through suicide), crises and mental health or other problems.Most are available 24 h per day and/or operate 365 days and/or offer extended hours, which means people can get the care they need when they need it and where they need it.This flexibility is facilitated by many digital services using multiple communication modalities (phone, online, mobile applications, email).Digital services are generally delivered by qualified counsellors or other mental health professionals, some are delivered by peers or trained volunteers, or a combination of options.Two services are delivered by First Nations peoples (13 YARN and National Indigenous Postvention Service).
Evaluation findings were located for 11 of the 20 digital services we reviewed.These evaluations show that digital services are valued by users, are effective (e.g., lead to improvements in wellbeing, increase help seeking, reduce suicidality), and/or contribute to service improvements.

Online navigation systems
To improve care coordination and integration and help people find the care they need, a range of service navigation systems have been created over time.Navigation -involving engagement, assessment, service identification, referral, and monitoring/follow-up -can be performed by staff or through online web-based applications [38].Ten online navigation systems funded by the Federal Government (with or without additional funding sources) were identified and are described in Appendix 4. Five online navigation systems are intended for use by consumers (and providers) including Head to Health, its redeveloped form as the National Mental Health Platform, the CBPATSISP Clearing House, Healthdirect and ReachOut.Three navigations systems are devoted to priority populations -two to First Nations peoples (CBATSISP Clearing House, WellMob) and one to young people (Reach Out -Tools and apps).Only three are suicide-prevention specific -Life in Mind, Suicide Prevention Australia's Best Practice Directory and the CBPATSISP Clearing House.Five are broader mental health navigation systems that include information regarding suicide prevention.A key challenge associated with maintaining service navigation systems is keeping them up to date.
Evaluation information was mentioned regarding seven of the navigation systems.For some, this involved conducting internal quality assurance and service improvement activities.Published evaluations were found for fewer navigation systems.For example, an independent evaluation of the Head to Health gateway reported it has been used by a substantial number of people and has potential to be cost effective, but needs to be more widely promoted and user experiences can be improved [39].Multiple studies have examined HealthPathways with a published review reporting that awareness and use are the most reported [40].This review also reported that the impacts and outcomes of HealthPathways are difficult to measure due to "limitations in primary data and the interconnectedness of change" and called for "specific methodologies sensitive enough to capture the impact … over time" [40], which is applicable to evaluating navigation systems more broadly.

Monitoring, evaluation and research activity
Federal and state and territory governments monitor and evaluate policies, programs and services, and fund research to strengthen the evidence base.Examples include funding the Australian Institute of Health and Welfare (AIHW) to conduct the National Suicide and Self Harm Monitoring Project [41], and the suicide prevention trials delivered through PHNs and their evaluations [36,37].
Additionally, the government commissions independent reviews and inquiries to help identify system problems, gaps, and opportunities for improvement.Examples include the National Suicide Prevention Adviser's Final Advice [7][8][9][10], the Productivity Commission's Mental Health Inquiry [42], the Royal Commission into Victoria's Mental Health System [43], and the National Review of Mental Health Programmes and Services [32].However, evaluation efforts including ensuring evaluation reports are available in the public domain need to be more consistent to ensure that implementation and outcome lessons are shared, effective approaches are sustained, and inadequate approaches are improved.

Research question 2. To what extent is government-led suicide prevention activity in Australia aligned with the focus areas in the NSPO framework for the new Strategy?
The scan identified that there is currently only partial progress in aligning government-led suicide prevention activity in Australia with the five focus areas in the NSPO framework for the new Strategy including: (1) strengthening protective factors and wellbeing; (2) mitigating the impact of known drivers of distress; (3) empowering earlier intervention; (4) providing accessible, comprehensive, and compassionate care; and (5) supporting long-term wellbeing.

Focus area 1: strengthening protective factors and wellbeing
The Pandemic Response strategy was the only nationally coordinated government-led plan included in the scan that explicitly focussed on strengthening protective factors [44].It included actions from the Federal and state and territory governments and multiple portfolios including those responsible for housing, employment and income support.
In terms of other policy and system responses aimed at strengthening protective factors and wellbeing under the remit of government-led suicide prevention activity, the emphasis on a whole-of-government approach in the suicide prevention policy documents included in the scan supported the principle of a comprehensive, coordinated policy and system response.Moreover, all the policy documents reviewed proposed multi-component approaches that included interventions aimed at strengthening protective factors and wellbeing such as early intervention, adopting a strengths-based approach, and building resilience.Strategies or elements of strategies focussed on First Nations suicide prevention foregrounded social and emotional wellbeing and cultural strengthening.In practice, most interventions named in strategies and agreements recognise and target individual risk factors (e.g., individual socio-demographic and contextual risk factors) [12].
Funded services and interventions reviewed in the scan, likewise, showed a predominantly risk-factor focus, with programs in educational settings being the most likely to focus on protective factors and general mental health and wellbeing.For example, the national initiative, Be You, is delivered to the entire school community and aims to promote and protect positive mental health in children and young people, although it also addresses risk factors such as bullying and the need for postvention [45].Other services/interventions that address protective factors such as interpersonal and community connection and resilience are generally only selectively applied, for example, to men as an at-risk group, young people, or First Nations-specific cultural strengthening.Thus, although policy documents acknowledge a need for a population-wide approach across a broad range of psychosocial and socioeconomic domains as part of a comprehensive approach to suicide prevention, the range of interventions proposed as well as the current service/ intervention landscape in the government-led suicidespecific domain are almost entirely risk-factor focussed and includes little activity at a population-wide level aimed at strengthening protective factors and wellbeing in general.

Focus area 2: mitigating the impact of known drivers of distress
All the policy documents reviewed in the scan acknowledged social determinants as contributing to suicide risk, and their adoption of the principle of a whole-of-government approach reflects an attempt to include social determinants as targets for intervention.
Individuals who are experiencing distress and/or suicidal crisis in the context of social determinant risk factors are mentioned in some strategies as high-risk populations and targeted for interventions (First Nations peoples, current and ex-ADF personnel, children and youth and LGBTIQ + people, residents in rural and remote regions, etc.).The main approach in terms of interventions for such individuals is to provide awareness and training across a diverse range of government agencies and services to recognise and potentially intervene to support those experiencing distress.The Queensland strategy is explicit in identifying every contact with a government agency as an opportunity for intervention [23].However, the scan did not identify any governmentled policies, services, or supports aimed at reducing the prevalence of distress in those contexts, or any systemwide measures to reduce the prevalence of those drivers.
The scan did not identify any strategy, service or intervention addressing upstream mitigation of social determinant-related drivers of distress although addressing distress in general as a risk factor for suicide is mentioned in a number of the bilateral schedules of the National Agreement [26].Likewise, the majority of activities mentioned in the joint regional plans and included in the service system scan focused largely on proximal interventions to address suicide distress and crisis, or gatekeeper training to identify and support individuals experiencing any type of distress not necessarily related to social determinants.
There is likely substantial activity and services in place dealing with distress that fell outside the scope of the scan because they may be in non-health policy and service areas, and/or in the non-government sector.

Focus area 3: empowering earlier intervention during life transitions
Significant life transitions can increase vulnerability to suicidal distress.Examples include disengagement and transition from educational settings, leaving the defence force, release from correctional facilities, relationship breakdown and change in family structures, migration and settlement, bereavement, and change in work status due to unemployment, illness or injury.Policy documents acknowledge the importance of early intervention during life transitions to differing extents.
A range of suicide prevention activities contribute to progressing earlier intervention during life transitions, such as the previously described Distress Brief Intervention Trial and postvention services (see Research question 1).Other early intervention activities, some funded through the NSPLSP, include: therapies or services targeting non-suicidal distress; programs such as the Villy app for people transitioning to civilian life from the military; services and programs for young people such as headspace providing a range of early intervention services in clinical, educational and workplace settings, and YouthLife4life and Batyr delivering peer-led mental health and suicide prevention activities in educational settings; and some PHN-commissioned services that target certain populations experiencing difficult life transitions (e.g., people experiencing homelessness, refugees and asylum seekers, people in contact or at risk of contact with the justice system, and children with parents who have mental health problems).
Improving whole of population awareness of suicide prevention including how to provide or seek help during difficult life transitions may also help to foster earlier intervention.The NSPLSP funds eight projects aimed at awareness raising to reduce the stigma around suicide and encourage help seeking.

Focus area 4: providing accessible, comprehensive, and compassionate care
All the policy documents recognised the need for accessible and coordinated care.Although compassionate care was not referenced in all policy documents, related concepts such, 'person-centred' care were mentioned.
Overall, Australia's suicide prevention services are largely affordable, with most, if not all, services being free of charge, which increases their likelihood of being accessible.The scan did not identify evidence for the comprehensiveness of the mental health and suicide prevention service system in terms of its capacity to respond to an individual's unique co-occurring stressors across disciplines beyond mental health and health (e.g., financial, housing, legal, interpersonal, etc.).
Findings addressing Research question 1 described several initiatives intended to facilitate accessible, comprehensive and compassionate care, including digital services (by overcoming access barriers), navigation systems and PHNs through their knowledge of local services, the Distress Brief Intervention Trial, postvention, and aftercare for all people who have made a suicide attempt.Two additional key system components that have the potential to help improve access and navigation are Head to Health centres and peer-based service models, described below.
The Head to Health Centres and satellite network (previously Adult Mental Health Centres [AMHCs] and HeadtoHelp) are community-based adult mental health services delivered by multidisciplinary teams who provide holistic, collaborative care.These include eight new Head to Health Centres, 24 satellites embedded into existing primary care settings, the continuation of the initial eight AMHCs (one in each state and territory), and a central intake phone service [46].The Initial Assessment and Referral Decision Support Tool (IAR-DST) is used to conduct central intake and is intended to improve accessibility, promote integration and facilitate referral to appropriate services [47].Evaluation of Head-toHelp shows that the service reduces psychological distress [48].This evaluation also made recommendations for improving the effectiveness and consistency of the IAR-DST including increasing awareness and training in its use, supporting it with an up-to-date service directory and regular evaluation and review [48].
Additionally, a new network of 15 Head to Health Kids Hubs (mental health and wellbeing centres) for children aged 0-12 years is under development through the bilateral agreements under the National Agreement [26].The Hubs aim to improve early intervention outcomes for children's mental health and wellbeing by providing comprehensive, multidisciplinary care for children and their families [49].This initiative builds on the findings of the National Children's Mental Health and Wellbeing Strategy [20] and the Productivity Commission's Mental Health Inquiry [42].
Peer-based services are increasingly emerging as nonclinical models that have potential to improve accessibility and provision of compassionate care [50,51].For example, around one third of the 18 projects funded under the NSPLSP's National Suicide Prevention Support for At Risk Populations and Communities component involve peer-delivered service models (e.g., Safe Spaces as an alternative to emergency department).
To facilitate compassionate care, the Australian Public Service Mental Health and Suicide Prevention Unit has developed Compassionate Foundations: Suicide Prevention Capability Suite [52].This is a self-directed, online foundational suicide prevention capability course to support positive interactions that promote connection and understanding.

Focus area 5: supporting long-term wellbeing
In principle, policy documents recognised the need for coordinated psychosocial support and integration of care for individuals experiencing a suicidal crisis and their families and carers.At the local state/territory and PHN level, work on developing care navigation and care pathways for people experiencing suicidal crisis to coordinate support is underway.However, mechanisms to deliver integration and coordination remain underdeveloped.
The fragmentation of the mental health and suicide prevention service sector and workforce capacity and distribution impact on the ability to support ongoing, coordinated care models.Moreover, in terms of ongoing support for mental health and wellbeing, the current government-led suicide prevention landscape reflects the underlying relatively short-term funding cycles and the lifecycles of government policy and strategies which present a challenge to establishing a system of sustainable services and programs needed to support long-term recovery.
Because the scan specifically focused on suicide prevention policy and services, the majority of which respond to acute suicidality, few services were identified with capacity or service models designed to support longer-term, less acute distress through to a state of wellbeing.

Research question 3. To what extent does government-led suicide prevention activity in Australia leverage the system enablers described in the NSPO framework for the new Strategy?
The scan identified that there is currently only partial progress in government-led suicide prevention activity in Australia leveraging the system enablers described in the NSPO framework for the new Strategy.This finding applies across all four system enablers including: (1) governance and collaboration across governments and portfolios; (2) embedding lived experience decision making and leadership; (3) data and evaluation; (4) workforce and community capability.

System enabler 1: governance and collaboration across governments and portfolios
Almost all the policy documents reference a commitment to a whole-of-government approach, particularly those which were more recently developed and those which explicitly drew on the National Suicide Prevention Adviser's Final Advice [7][8][9][10].However, details about how this approach would be operationalised was variable and limited.New South Wales and Queensland strategies offered more detail including which portfolio or agency have carriage of strategy elements [23,24].
Given that many strategies are currently under, or will soon be due for, renewal there is an opportunity to progress coordination and integration of suicide prevention across and between jurisdictions.Most policy documents do not come with budgets attached, with some but not all jurisdictions providing implementation plans.Likewise, the short tenure of many suicide prevention strategies impacts on their ability to guide long-term structural changes that may be required to achieve a strong wholeof-government approach.

System enabler 2: embedding lived experience decision-making and leadership
Most of the policy documents (over 80%) and one third of joint regional plans specifically referenced people with lived experience and the process of co-design.
Lived experience was one of the specific target areas of the NSPLSP and lived experience leadership in suicide prevention, postvention, and peer support were cited as key achievements of the National Suicide Prevention Trial [53].According to the National Suicide Prevention Strategy for Australia's Health System 2020-2023 [54], the term 'evidence-informed' encompasses four sources of evidence, including the qualitative insights of people with lived experience of suicide.
Specific actions related to lived experience at the national level were identified.For instance, the Fifth Plan [28] included involving consumers and carers in the Suicide Prevention Subcommittee reporting to Mental Health Drug and Alcohol Principal Committee and in the evaluation of the Fifth Plan.Further, to promote lived experience research, co-design and/or service delivery, the ALIVE National Centre for Mental Health Research has been established, the Roses in the Ocean CARE connect service (a peer operated suicide prevention call-back service) has been funded, and a collaboration has been formed between the Black Dog Institute (University of New South Wales) and the Aboriginal and Torres Strait Islander Lived Experience Centre.
At the state and territory level, policy documents mention plans to involve people with lived experience of suicide through co-design in redesign of mental health services, employment and membership in suicide prevention policy and governance, as well as development and trialling of peer support and peer-led initiatives.

System enabler 3: data and evaluation
The scan identified a range of issues related to suicide prevention and self-harm data and evaluation.Problems include concerns about the availability and quality of routinely collected data, inconsistent monitoring and evaluation, and limited evidence for effective interventions.
Most policy documents note the need for improved data and identify gaps in the current data.For example, there are inconsistencies in, and lack of recording of, suicide attempts across services (between jurisdictions, hospital vs. ambulance records, etc.) [54].Additionally, problems applicable to broader health data also apply to suicide prevention and self-harm data, such as difficulty identifying priority populations including First Nations peoples, people who identify as LGBTIQ + and people from CALD backgrounds [8][9][10]16].
Monitoring and evaluation of strategies and plans that guide suicide prevention activity is inconsistent.
However, the National Mental Health Commission independently monitors and reports on the national mental health and suicide prevention system.Monitoring and evaluation of joint regional plans and the interventions, services, and programs they include is inconsistently specified.Many, but not all, Australian suicide prevention services and programs have been evaluated.Determining the effectiveness of all services and programs is important to increase our understanding and knowledge of what works to prevent, and respond to, suicide, and for government to make informed decisions about services and programs in which to invest.
The scan also identified activities that have been implemented to address some of the suicide prevention and self-harm data and evaluation problems identified.Key among these are the National Suicide and Self-harm Monitoring Project and the LIFEWAYS Project.
The Federal Government has funded the AIHW to conduct the National Suicide and Self-harm Monitoring Project from 2019-2020 to 2024-2025.The project has developed and is expanding a monitoring system to improve the quality, accessibility and timeliness of suicide and self-harm data in at-risk groups and regions in Australia [41].The project intends to support: the development of effective policies, programs and interventions; the delivery of tailored services; reduction in suicide and self-harm rates; and tracking progress [55].
Funded under the NSPLSP, the LIFEWAYS Project provides capacity building of the suicide prevention research workforce and translation of research into policy and practice.Its research priorities study identified that existing research and evidence is heavily weighted toward risk factors, and future suicide prevention research should address suicide attempts, protective factors, social determinants, community settings, and interventions, and focus on strengthening effective research translation into practice [56].These priorities represent areas requiring increased emphasis rather than the deprioritising of research with other focuses (e.g., epidemiology, suicide, suicidal ideation, suicide method, priority groups, etc.).

System enabler 4: workforce and community capability
Over 75% of the policy documents refer to 'suicide prevention workforce' , although in some it was included in the broader category of 'mental health workforce' .Over one third of documents include 'peer/lived experience workforce' in paid, voluntary or advocacy positions, in suicide prevention or in a broader mental health context.
The suicide prevention workforce covers diverse settings, including clinical (e.g., emergency department staff, mental health specialists) and non-clinical frontline staff (e.g., paramedics, police), and staff providing ongoing management and care (e.g., GPs, mental health/allied health professionals).Coronial and justice staff, media, teaching staff, and community support professionals can also be included in this category.The multidisciplinary suicide prevention workforce may reflect the whole-ofgovernment approach to suicide prevention and activities to ensure provision of services and supports across a wide range of portfolios and settings.
In terms of capabilities, the Suicide Prevention Workforce Development and Training Plan for Tasmania [57] specifies skills required for various workforce categories.Documents reference several existing and new training programs and other initiatives targeting the suicide prevention workforce, including peer workforce, across a range of settings at both the national and state and territory level, including funding for a Centre for Mental Health Workforce Development in Victoria.The Emerging Minds: National Workforce Centre for Child Mental Health aims to build the capacity of mental health workforce focused on children aged 0-12 years and their families.
Consistent with the National Suicide Prevention Adviser's Final Advice [7][8][9][10], under the National Agreement [26], work is underway involving collaboration between parties to develop the new National Suicide Prevention Workforce Strategy in 2024.This strategy will include workforces and settings where individuals at risk of suicide may present, such as personnel from government departments, service providers, social services, employer groups, community-based organisations, and educators.The National Lived Experience Workforce Guidelines [58] aim to create role delineations providing opportunities for contact with consumers, carers, and grassroots advocacy, as well as identifying anti-stigma interventions.
The documents included in the scan also refer to provision of support and retention of skilled and compassionate suicide prevention workforce, including supporting the mental health of health professionals, peer workers, volunteers, and remote suicide prevention workforces.
The NSPLSP offers essential sector leadership and resources particularly through six projects funded to contribute to knowledge gain, exchange, and translation, and build capacity of the suicide prevention sector.In addition, seven of the 18 direct service delivery projects funded via the NSPLSP involve peer-delivered services, ranging from support delivered by youth in educational or (rural) community settings, men in relationship distress, veterans, to peers in Pop-up Safe Spaces.

Summary of findings
This study aimed to describe government-led suicide prevention activity in Australia and assess the extent of activity alignment with the focus area and enabler components of the NSPO framework underpinning the new Strategy.Both policy documents (plans, strategies, and agreements) and services and programs were considered.Australia's suicide prevention efforts are significant as demonstrated by activities ranging from policy documents intended to guide and plan activity, the National Mental Health and Suicide Prevention Agreement [26] committing the Federal Government and jurisdictions to work together, and the availability of national, state, PHN-region based and digital services and programs.However, we identified only partial or inconsistent progress across each focus area and enabler.

Implications for suicide prevention policy, practice, and evidence-base
Government-led/funded suicide prevention approaches in Australia are mostly selective or indicated.There is less emphasis on universal approaches, wellbeing promotion, strengthening protective factors and mitigating the impact of known drivers of distress -which require more sustained attention going forward [56].In addition, there is limited evidence to demonstrate a whole-of-government or whole-of-system approach is operating in Australia.Neither of these findings is surprising given that suicide prevention in Australia is in a period of transition following the National Suicide Prevention Adviser's Final Advice [7][8][9][10], which is still relatively recent, and the system will take time to reorient.
Consequently, there are numerous opportunities to improve Australia's government-led suicide prevention activity.Improving cross-portfolio and cross-jurisdiction collaboration and coordination is relevant to all these opportunities.Importantly, Australia's suicide prevention policy and practice efforts are not based on a shared framework of suicide prevention, which is crucial to guide collective progress.A shared understanding might be based on the blueprint paper Understanding Suicide and Self-harm [12,13] and the forthcoming new Strategy, both of which consider the role of social determinants and individual-level risk factors and favour a whole-ofgovernment approach that addresses diverse drivers of distress.
There is potential to improve progress across the focus areas outlined in the NSPO framework by drawing on the evidence for social determinants of population health wellbeing, which requires a cross sectoral systems-based approach.Conceptual models that aim to promote such an approach could be applied such as a Canadian framework emphasising the role of collective learning [59] or the Collective Impact Suicide Prevention framework developed in New Zealand [60] highlighting the need for dynamic leadership and resourcing a supporting ('backbone') agency to develop and implement cross-sectoral committees and actions.
At a practical level, strategic social services policy and action should support financial security [61] and stable housing [62] given that socio-economic disadvantage (as indicated by interrelated domains such as employment, income, housing, and education) is associated with increasing risk for suicide and self-harm [63,64].For example, Medical-Financial Partnerships (MFPs) in the US, involve collaborations between the health sector and financial services organisations to improve health by reducing patient financial stress [65].Additionally, there are opportunities to adapt or enhance existing services and programs to improve suicide prevention.For example, modelling has shown that health system reform and training health care professionals to detect and reduce suicide risk has the largest potential to reduce the suicide rate [66].Furthermore, although digital services and online navigation systems help improve access to services round the clock [67], consumers and service providers need to be aware of their existence and ongoing effort is needed to keep them up to date [40].
There is also potential to better leverage the enablers in the NSPO framework.Cross-sector suicide prevention governance, coordination, and alignment could be improved in Australia.For example, consideration could be given to producing a cross-government suicide prevention workplan, which commits each government portfolio to taking action on suicide and outlines deliverables and timeframes for monitoring progress against commitments, as exemplified by the UK [68].To better embed lived experience decision making and leadership, policy and service delivery principles could draw on findings from a systematic review showing that stakeholder involvement in developing community-based suicide prevention interventions may improve engagement and create opportunities for people with lived experience of a suicidal crisis to provide input, and the need to evaluate the long-term outcomes of co-produced suicide prevention interventions [69].
Suicide prevention efforts, particularly those focussed on social determinants of health, are currently hampered by a lack of evidence for their effectiveness and cost-effectiveness making it difficult for government to know which interventions to invest in [70,71].Because suicide is a statistically rare event, many potentially useful suicide prevention interventions cannot be evaluated using gold-standard randomised controlled trials (RCTs), particularly universal interventions that target the whole population [70,72].The evidence base can be bolstered by conducting rigorous monitoring, evaluation and research based on well-articulated program logic, shared frameworks of suicide and its prevention, and expected intervention outcomes [72][73][74].The Outcomes Framework being developed by the NSPO will help promote a shared understanding of outcomes.Additionally, sector wide opportunities for timely cross linkage surveillance data in the service system (e.g., Suicide and Selfharm Monitoring System established by the AIHW) and research environment (e.g., universities) could be capitalised on to improve understanding of suicide attempts and more upstream indicators of distress and wellbeing [75].
Finally in terms of opportunities to strengthen and integrate the clinical and non-clinical suicide prevention workforce, although various relevant competency frameworks exist [10,[76][77][78][79], standalone national suicide prevention workforce strategies are lacking internationally [80].The NSPO led development of the Australian Suicide Prevention Workforce Strategy will help fill this international policy gap.

Limitations and future research
This study does not provide a comprehensive picture of all suicide prevention activity occurring in Australia.It focused primarily on Federal Government (mental) health portfolio-led suicide prevention programs and services, although state and territory-level strategies, and Federal, state and territory joint initiatives were also included.As a result, for programs and services, there is only partial representation of those occurring in other government jurisdictions and portfolios and the community not-for-profit sector.Also, wellbeing promotion activities outside the suicide prevention sector were not included in the scan.
To provide a more complete picture of suicide prevention activity in Australia, future research should focus on activity occurring in non-health portfolios (e.g., social services, employment, education, justice).

Conclusions
This study found that current government emphasis on and investment in suicide prevention activity, together with strong commitment to lived experience and cross sectorial collaboration, are substantial and appropriate.It has also identified many opportunities to further progress suicide prevention and response efforts as a nation.Suicide prevention efforts can be enhanced by adopting a shared understanding of suicide, which includes the diverse drivers of suicidal distress, and by improving protective factors and social wellbeing.The blueprint paper, Understanding Suicide and Self-harm [12,13], and the National Suicide Prevention Strategy the NSPO is developing contribute to this shared understanding.This, in turn, will have implications for expanding, capacity building of, and integrating the clinical and nonclinical suicide prevention workforce.The development of the National Suicide Prevention Workforce Strategy by the NSPO will help to drive these reforms.Furthermore, system wide suicide prevention approaches need governance and leadership structures and mechanisms including lived experience leadership (particularly representing priority groups) to ensure they are coordinated, collaborative and informed by the needs of people with lived experience.Findings from this environmental scan illustrate how three decades of Australian government strategies, agreements, services and programs, and investment have been operationalised.This information is useful for comparing approaches in other countries and for informing government policy and resource allocation elsewhere.

PHN region
Plan title 21.Tasmania Rethink 2020 a state plan for mental health in Tasmania 2020-2025 and Rethink 2020 implementation plan [120] 22.South Eastern Melbourne South Eastern Melbourne's plan for mental health, suicide prevention and alcohol and other drugs 2020-2025 [121] 23.Western Victoria Joint regional mental health and suicide prevention foundation plan [122] 24.Eastern Melbourne Regional integrated mental health, alcohol and other drugs and suicide prevention plan for eastern and north eastern Melbourne 2019-2024 [123] 25.Gippsland Gippsland mental health and suicide prevention plan: foundational plan 2019-2022 [124] 26.Murray Together: A regional approach to mental health, alcohol and other drugs and suicide prevention foundation plan [125] 27.North Western Melbourne Regional Foundation Plan blueprint foundation plan 2020-22 [126] 28.WAPHA -Perth South, Perth North, Country WA PHNs WA Foundation Plan for Mental Health, Alcohol and Other Drug Services, and Suicide Prevention [127] Note.At the time of our analysis in November 2022, we found 28 regional plans representing 30 of Australia's 31 PHN regions.The WA regional plan included three PHN regions; and the North Coast area regional was released in December 2022 and was therefore not included in our analysis

Table 2
Key policy documents included in scan and data extracted 'universal' interventions target the whole population; 'selective' interventions, people who are at-risk of suicidal ideation or behaviours; and 'indicated' interventions, people who are already suicidal or self-harming.

Table 3
Key suicide prevention and response initiatives under the National Agreement

ACTIVITY 3: CENTRE OF BEST PRACTICE IN ABORIGINAL AND TORRES STRAIT ISLANDER SUICIDE PREVENTION (CBPATSISP)
[33]ctiveSource: A. Warland, personal communication, 2 November 2022.Details of activities expanded using Department of Health and Aged Care[33]and/or web searches a Universal, target the whole population without necessarily identifying individuals who might be at risk of suicide or self-harm; Selective, target individuals who are not yet thinking about suicide or engaging in self-harm, but who are at-risk because they exhibit risk factors that predispose them to do so in the future.This includes interventions directed at gatekeepers working with at-risk populations.Indicated, target individuals who are already suicidal or self-harming[13]

Appendix 4 Online navigation systems Organisation Service Description Target group Evaluation
a Previously Suicide Prevention Hub in collaboration with Life in Mind